Basic Information
Provider Information
NPI: 1003000464
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WOLF
FirstName: LAUREL
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: P.T.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1837 RIDGE RD
Address2:  
City: KLAMATH FALLS
State: OR
PostalCode: 976035361
CountryCode: US
TelephoneNumber: 5418840376
FaxNumber:  
Practice Location
Address1: 1837 RIDGE RD
Address2:  
City: KLAMATH FALLS
State: OR
PostalCode: 976035361
CountryCode: US
TelephoneNumber: 5418840376
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/29/2007
LastUpdateDate: 08/29/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X21668CAN Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 
225100000X3434WIN Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 
225100000X1722ORY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


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